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Cureus Jul 2021Previously, the management of gunshot wounds (GSWs) to the anterior abdomen required exploratory laparotomy; however, this was associated with a considerable number of...
Previously, the management of gunshot wounds (GSWs) to the anterior abdomen required exploratory laparotomy; however, this was associated with a considerable number of non-therapeutic surgeries. The use of non-operative management (NOM) of GSW to the abdomen is controversial, with many surgeons sceptical to accept this into their practice. The NOM of GSW to the abdomen employed in a selected group of patients has been shown to be safe and acceptable. Penetrating GSW to the thoraco-abdomen, back and lateral abdomen has been the most successful compared to the anterior penetrating wound. Most of the anterior GSWs to the abdomen are associated with viscus injury and require exploratory laparotomy. We report the case of a 58-year-old male who presented with a single GSW to the epigastrium with a contrast computed tomography scan demonstrating grade 3 liver lacerations, contusion to the right adrenal gland, with moderate free fluids in the retroperitoneum and the pelvis. The patient was haemodynamically stable and managed successfully with NOM. It is one of the safe routes of anterior penetration of GSW to the abdomen and treated with conservative management.
PubMed: 34513396
DOI: 10.7759/cureus.16789 -
Anatomical Record (Hoboken, N.J. : 2007) Oct 2021The genera Mitophis and Tetracheilostoma comprise two extant lineages of small-sized threadsnakes that exclusively inhabit several islands of the West Indies. Even...
Evolutionary treasures hidden in the West Indies: Comparative osteology and visceral morphology reveals intricate miniaturization in the insular genera Mitophis Hedges, Adalsteinsson, & Branch, 2009 and Tetracheilostoma Jan, 1861 (Leptotyphlopidae: Epictinae: Tetracheilostomina).
The genera Mitophis and Tetracheilostoma comprise two extant lineages of small-sized threadsnakes that exclusively inhabit several islands of the West Indies. Even though leptotyphlopids are known for their extremely reduced size, miniaturization has only been hypothesized to reflect insular dwarfism for the genus Tetracheilostoma. Herein, we aim to describe the comparative osteology and visceral morphology of both genera, investigating and discussing their several internal morphological simplifications and novelties. Our results indicate that these taxa exhibit several autapomorphies mostly concentrated in the dorsoposterior skull elements and maxillae, as well as in their axial skeleton and viscera. These novelties and simplifications are most likely a result of extreme miniaturization driven by the evolutionary constraints or ecological opportunities possibly imposed by the "island rule." Both Mitophis and Tetracheilostoma distinguish from all other Epictinae in lacking a dentigerous process in the maxillae, by having the prootic fused to the otooccipital, and by the lack (except in comparison to a few Epictia) of a cervical vertebrae intercentrum I. Additionally, Mitophis can be distinguished from other Epictinae by the participation of the unpaired supraoccipital in the dorsal border of the foramen magnum, by the absence of the pleurapophyses in the caudal vertebrae, by a higher number of liver segments, and by the extreme degeneration of the pelvic rudiments. Tetracheilostoma differs from other Epictinae by lacking a distinct supraoccipital, which is fused to the parietal. Thus, our results reinforce that morphological characters are extremely valuable for leptotyphlopid systematics given their extremely conserved external morphology.
Topics: Miniaturization; Osteology; Research; West Indies
PubMed: 34296825
DOI: 10.1002/ar.24716 -
Cureus Jul 2021Retroperitoneal abscesses are relatively uncommon in infants and children. They carry a high rate of morbidity due to insidious onset and pose a diagnostic challenge....
Retroperitoneal abscesses are relatively uncommon in infants and children. They carry a high rate of morbidity due to insidious onset and pose a diagnostic challenge. Here we report a case of spontaneous retroperitoneal methicillin-resistant (MRSA) infection in a two-year-old patient. The patient was successfully treated with antibiotics and surgical washout and drainage. A retroperitoneal abscess is usually found in patients with a history of osteomyelitis, seeding of post-traumatic pelvic hematomas, post radiation, or perforated hollow viscus including but not limited to: perforated appendicitis, bowel perforations due to foreign objects or malignancy, or perforated diverticulitis. Most of these conditions are usually found in the adult population. As per a recent literature search, there are no reported cases of a spontaneous retroperitoneal MRSA abscess in the pediatric population without risk factors.
PubMed: 34262825
DOI: 10.7759/cureus.16111 -
Pain Apr 2022Clinical evidence indicates dorsal root ganglion (DRG) stimulation effectively reduces pain without the need to evoke paresthesia. This paresthesia-free anesthesia by...
Clinical evidence indicates dorsal root ganglion (DRG) stimulation effectively reduces pain without the need to evoke paresthesia. This paresthesia-free anesthesia by DRG stimulation can be promising to treat pain from the viscera, where paresthesia usually cannot be produced. Here, we explored the mechanisms and parameters for DRG stimulation using an ex vivo preparation with mouse distal colon and rectum (colorectum), pelvic nerve, L6 DRG, and dorsal root in continuity. We conducted single-fiber recordings from split dorsal root filaments and assessed the effect of DRG stimulation on afferent neural transmission. We determined the optimal stimulus pulse width by measuring the chronaxies of DRG stimulation to be below 216 µs, indicating spike initiation likely at attached axons rather than somata. Subkilohertz DRG stimulation significantly attenuates colorectal afferent transmission (10, 50, 100, 500, and 1000 Hz), of which 50 and 100 Hz show superior blocking effects. Synchronized spinal nerve and DRG stimulation reveals a progressive increase in conduction delay by DRG stimulation, suggesting activity-dependent slowing in blocked fibers. Afferents blocked by DRG stimulation show a greater increase in conduction delay than the unblocked counterparts. Midrange frequencies (50-500 Hz) are more efficient at blocking transmission than lower or higher frequencies. In addition, DRG stimulation at 50 and 100 Hz significantly attenuates in vivo visceromotor responses to noxious colorectal balloon distension. This reversible conduction block in C-type and Aδ-type afferents by subkilohertz DRG stimulation likely underlies the paresthesia-free anesthesia by DRG stimulation, thereby offering a promising new approach for managing chronic visceral pain.
Topics: Animals; Chronic Pain; Colorectal Neoplasms; Ganglia, Spinal; Mice; Paresthesia
PubMed: 34232925
DOI: 10.1097/j.pain.0000000000002395 -
Case Reports in Orthopedics 2021Rotational displaced pelvic ring injuries are associated with internal injuries to both the gastrointestinal and genitourinary viscera and anatomic structures. Vaginal...
INTRODUCTION
Rotational displaced pelvic ring injuries are associated with internal injuries to both the gastrointestinal and genitourinary viscera and anatomic structures. Vaginal lacerations and open genitourinary-associated injuries are at increased risk of mortality due to sepsis. . This case presents a 65-year-old female status post-pedestrian-vehicle struck diagnosed with an open pelvic fracture with extension into the outer one-third of the vaginal wall. The patient was successfully treated with emergent surgical debridement, pelvic stabilization, and internal placement of a novel combination of metronidazole antibiotic gel and vancomycin/tobramycin Polymethyl methacrylate beads.
CONCLUSION
No evidence of infection was observed with the use of topical metronidazole-coated vancomycin/tobramycin Polymethyl methacrylate beads for contaminated open pelvic fracture injury involving the vaginal wall. Further research on antibiotic gels for use in high-risk open fractures is required.
PubMed: 34055438
DOI: 10.1155/2021/5594270 -
International Journal of Surgery Case... Jun 2021Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized...
INTRODUCTION
Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. It can be associated with abdominal andthoracic lesions, particularly cardiac, which can be life-threatening.
MATERIALS AND METHODS
Our work is a retrospective case report with a descriptive aim concerning a patient operated for a post-traumatic diaphragmatic rupture within the department of general surgery of CHU Ibn Rochd Casablanca. This work has been reported in line with the SCARE 2020 criteria (17).
CASE PRESENTATION
A 60-year-old patient was admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration. The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility. The thoraco-abdomino-pelvic CT scan revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome. The decision was to directly send the patient to the operating room. Exploration found a large left diaphragmatic breach of 20 cm, a denudation of the pericardia, a medium-abundant hemoperitoneum and a hematoma of the right mesocolon. The procedure consisted of right hemicolectomy with ileocolic anastomosis, treatment of a diaphragmatic breach with a 2-silk raphia, thoracic drainage with a Joly drain, pericardial drainage with a Joly drain, pre-anastomotic drainage with 2 delbet slides, drainage of the Douglas and left subthreshold with 2 Salem catheters. The post-operative follow-up was simple.
DISCUSSION
Diaphragmatic rupture is a rare and difficult to diagnose condition. Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% (1). Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% (9). The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain but it can be asymptomatic. Medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself. The chest X-ray is currently the first examination to be requested (4) and also helps in the diagnosis of injuries and diaphragm rupture (13). Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm.
CONCLUSION
Diaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting.
SUMMARY
Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. The lesions are more frequent in the left diaphragmatic dome compared to the right one, and exceptionally bilateral. Pericardial rupture following blunt chest trauma is rare and associated to a high mortality rate. It is often unrecognized and goes unnoticed in the acute phase. The most common clinical symptoms of diaphragmatic ruptures are respiratory distress and diffuse abdominal pain, as it can be asymptomatic. Its diagnosis is essentially radiological using CT scan, and requires emergency surgical treatment as soon as the diagnosis is suspected, in order to avoid the dreaded complications. Traumatic diaphragmatic rupture remains a diagnostic and therapeutic challenge. We report the case of a patient who presented a post-traumatic diaphragmatic rupture with pericardial damage operated in the visceral emergency department at the Ibn Rochd Hospital c in Casablanca, Morocco.
PubMed: 34029846
DOI: 10.1016/j.ijscr.2021.105970 -
Chinese Journal of Traumatology =... May 2021Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to...
PURPOSE
Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities.
METHODS
We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted.
RESULTS
In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001).
CONCLUSION
IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.
Topics: Abdominal Injuries; Ecchymosis; Female; Humans; Male; Pelvis; Retrospective Studies; Wounds, Nonpenetrating
PubMed: 33745761
DOI: 10.1016/j.cjtee.2021.03.002 -
Maternal Health, Neonatology and... Jan 2021Vertical transmission of covid-19 is possible; its risk factors are worth researching. The placental changes found in pregnant women have a definite impact on the foetus.
INTRODUCTION
Vertical transmission of covid-19 is possible; its risk factors are worth researching. The placental changes found in pregnant women have a definite impact on the foetus.
CASE PRESENTATION
We report a case of a 25-year-old woman, gravida 3, para 2 (2 alive children), with a history of two caesarean deliveries, who was infected by the SARS-CoV-2 during the last term of her pregnancy. She gave birth by caesarean at 34 weeks of gestation to a newborn baby also infected with SARS-CoV-2. The peri-operative observations noted several eruptive lesions in the pelvis, bleeding on contact. Microscopic examination of the foetal appendages revealed thrombotic vasculopathy in the placenta and in the umbilical cord vessels.
CONCLUSION
This case is one of the first documented cases of COVID-19 in pregnancy in sub-Saharan Africa. We strongly suggest obstetricians to carefully examine the aspect of the peritoneum, viscera and foetal appendages in affected pregnant women.
PubMed: 33472696
DOI: 10.1186/s40748-021-00127-5 -
BMC Urology Jan 2021Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused...
BACKGROUND
Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused surgeons. The aim of this study was to describe the periprostatic neurovascular bundles and their relationship with the fascicles around prostate and provide the accurate morphologic knowledge of periprostatic tissue for prostate operation.
METHODS
The pelvic viscera were obtained from 26 adult male cadavers. They were embedded in celloidin and cut into successive slices. The slices were explored with anatomic microscopy. 3-Dimensional reconstruction was achieved with celloidin sections and series software.
RESULTS
The prostatic capsule which surrounded the dorsal, bilateral aspect of the prostate was attached ventrally to anterior fibrous muscular stroma (AFMS). The lower part of the striated sphincter completely embraced the urethral; the upper part of this muscle covered the lower ventral surface of prostate. The upper ventral surface of prostate is covered by the circular muscle of detrusor. The levator fascia and the capsule adhered on the most convex region of the lateral prostate, but separated on the other region. The pelvic neurovascular bundles (PNVB) divided into the anterior and posterior divisions. The anterior division continued as dorsal vascular complex (DVC). The distal part of DVC entered into penile hilum. The posterior division continued as neurovascular bundles, and then as the cavernous supply (CS). The distal part of CS joined into pudendal neurovascular bundles.
CONCLUSIONS
The capsule and AFMS formed a pocket like complex. There were anterior and posterior neurovascular approaches from PNVB to penile hilum.
Topics: Aged; Aged, 80 and over; Blood Vessels; Cadaver; Collodion; Humans; Male; Middle Aged; Nervous System; Prostate
PubMed: 33407368
DOI: 10.1186/s12894-020-00778-0 -
International Journal of Surgery Case... 2020A congenital diaphragmatic hernia (CDH) is rarely diagnosed in adults and can allow passage of abdominal viscera into the chest cavity. A particularly rare association...
INTRODUCTION
A congenital diaphragmatic hernia (CDH) is rarely diagnosed in adults and can allow passage of abdominal viscera into the chest cavity. A particularly rare association is a wandering spleen due to absence of its diaphragmatic and retroperitoneal attachment which predisposes to elongation of the vascular pedicle with risk of torsion, infarction and rupture.
PRESENTATION OF CASE
A 17-year-old girl presented with a two-day history of increasing abdominal pain. Examination identified an abdominal mass. Computer tomography (CT) chest, abdomen and pelvis revealed a significantly enlarged wandering spleen with signs of torsion and an associated large left CDH with viscera in the chest cavity. The patient proceeded to an open splenectomy and repair of CDH. Post-operatively the patient developed ileus and required a temporary chest tube for pneumothorax, but otherwise progressed well.
DISCUSSION
Untreated CDH with a symptomatic wandering spleen is an extremely rare diagnosis with only one similar previous case report. Clinical detection is unlikely, making CT scanning the diagnostic test of choice. Surgery is recommended given the high morbidity and mortality of associated complications of both conditions. Splenic preserving options are favoured, however the majority of identified cases require splenectomy because of associated torsion or splenomegaly. Reduction of the CDH should be performed with primary closure of the defect and mesh reinforcement where possible.
CONCLUSION
CDH with associated wandering spleen in adults presents an extremely rare but clinically important diagnosis. Prompt surgical management as reported in this case should be performed to minimise immediate and future complications.
PubMed: 33137668
DOI: 10.1016/j.ijscr.2020.10.049